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New in 2025: CMS Standards for Initial Appointment Wait Times
CMS 2025 Final Rule: New Behavioral Health Requirements for MA Plans
CMS Directory Accuracy Audits and Sanctions: Achieving True Directory Accuracy

New in 2025: CMS Standards for Initial Appointment Wait Times

How to achieve compliance with Centers for Medicare & Medicaid Services (CMS) wait time standards

The healthcare landscape just got more demanding. Starting January 1, 2025, Qualified Health Plan (QHP) issuers on the federal exchanges must meet strict new standards for initial appointment wait times. This means proving that 90% of the time, new patients can schedule primary care and behavioral health appointments within 15 and 10 days, respectively. Fail to comply? You’ll need to expand your network.

CMS wait times standard appointment times grid

Decoding the New Appointment Wait Time Standards

CMS is tackling the growing problem of long wait times head-on. The new standards, which must be assessed by a third party unaffiliated with the health plan (more on that below), require QHPs to demonstrate timely access to care. Here’s a breakdown of the standards:

  • Primary Care: Appointments within 15 days
  • Behavioral Health: Appointments within 10 days
  • 90% Compliance Target: Health plans must meet this target with a confidence level of +/- 5% or face mandatory network expansion.

Specialists will be surveyed in future years and that standard will be 30 days.

The Stakes Are High: Why CMS is Prioritizing Wait Times

Long wait times create barriers to care, frustrate patients, and can have serious consequences for health outcomes. As the media has reported, in some cases, patients are not able to schedule an appointment for 6-12 months from the first time they reach out for care.

CMS is “particularly concerned with the ability of new patients to schedule appointments with in-network providers” and secret shopper calls, from independent third-party entities, must take place from January to May of this year.

CMS is taking action to address this issue, recognizing the urgent need for timely access to both primary care and behavioral health services.

The CMS wait time requirements will be assessed during annual secret shopper surveys conducted by independent third-party entities hired by the health plans. The standards are detailed in CMS’ Appointment Wait Time Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs).

The completed surveys must be submitted to CMS with compliance rates, percentage of non-responsive providers, and contracts with third-party entities. Submissions are due in mid-June.

Veda: Your Partner in Achieving and Exceeding CMS Compliance

Veda’s proprietary provider data technology can help QHPs meet and exceed the wait time standards issued by CMS.

Meeting these new standards requires accurate, real-time data on provider availability. This is where Veda shines.

The first step in ensuring you can deliver on wait time requirements is auditing your directories for accurate provider-at-location data and keeping those records current.

Then, Veda can help you identify and strategically fill gaps in your network for known provider needs (from an adequacy perspective), particularly PCPs and Telehealth. This will ensure adequate access to care across all specialties and service areas.

Veda’s Dashboard: Your CMS Audit Command Center

Veda’s intuitive dashboard provides a clear, real-time view of your provider data accuracy. View your performance through a simulated CMS audit score, identify areas for improvement, and take proactive steps to ensure compliance.

Offering profiles on providers and roster automation, Veda offers true directory accuracy for providers, facilities, and groups. Veda’s solutions can help you not only meet the new CMS wait time standards but exceed them, all while enhancing your member satisfaction and solidifying your position in the market.

Don’t wait for secret shopper surveys to reveal gaps in your network. Request a demo from Veda today and ensure you are ready for this new era of provider data accuracy. By identifying and addressing gaps in your network with Veda’s powerful analytics, you are ensuring adequate access to care across all specialties and service areas.

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CMS 2025 Final Rule: New Behavioral Health Requirements for MA Plans

Mental Health Awareness Month and Summary of New CMS Final Rule

Fitting for Mental Health Awareness Month, the Centers for Medicare & Medicaid Services (CMS) recently released its 2025 Final Rule that, among other things, aims to improve access to behavioral health providers for Medicare Advantage members.

Ready to learn about the CMS 2025 Final Rule and Veda’s strategic approach to its behavioral health network requirements?

The CMS 2025 Final Rule significantly expands the behavioral health network requirements for Medicare Advantage (MA) health plans. As reported by Fierce Healthcare, all Medicare Advantage plans will likely see increased administrative burdens due to the behavioral health network expansion requirements.

Not only is Veda a proven and trusted partner for achieving compliance with CMS requirements, Veda’s solutions are unrivaled in their ability to help health plans verify, expand, improve, and map their behavioral health networks.

Here are the behavioral health requirements covered in the Contract Year 2025 Medicare Advantage and Part D Final Rule and Veda’s approach:

New “Outpatient Behavioral Health” Category Added to Network Adequacy Evaluations 

Building upon CMS’s recent addition of a new benefit category for mental health counselors (MHCs) and marriage and family therapists (MFTs)—and recognizing that many MHCs and MFTs practice in outpatient behavioral health facilities—CMS has expanded its network adequacy requirements to include a new category called “Outpatient Behavioral Health.”

What Can Veda Do?

Veda’s curated dataset includes accurate information for even the hardest-to-validate specialties, credentials, and facility types— requiring no additional burden on health plans and health systems.

Wide Range of Specialists Included in “Outpatient Behavioral Health” Category

More specialties and outpatient care classifications were added to solve behavioral health provider shortages. The specialists in the new “Outpatient Behavioral Health” category include MHCs, MFTs, Opioid Treatment Program providers, Community Mental Health Centers, addiction medicine physicians, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs).

What Can Veda Do?

Veda offers current and complete outpatient behavioral health provider profiles, on each of the specialties above, containing the necessary details to contract with providers and meet adequacy requirements.

Skill Sets of Certain Behavioral Providers Must Be Verified 

To address concerns that NPs, PAs, and CNSs have the requisite skills and training to address the behavioral health needs of plan members, MA plans must independently verify that the providers they are adding to their network have furnished (or will furnish) behavioral health services to at least 20 patients within a 12-month period using information such as (i) MA plan’s claims data, (ii) prescription drug claims data, (iii) EHRs, or (iv) similarly reliable data.

What Can Veda Do?

Veda partners with customers to develop effective ways to complete the requisite independent verifications, utilizing the best data available in the industry. Our proprietary Vectyr database is updated 24/7 to include the most up-to-date, complete, and accurate provider data in the behavioral health space. This data can help MA plans verify behavioral health providers and comply with CMS’s requirements.

“Outpatient Behavioral Health” Facility Added to Time & Distance Standards and Telehealth Specialty Requirements

CMS now includes the “Outpatient Behavioral Health” facility specialty in the list of specialty types that will receive a 10% credit toward meeting time and distance standards. Additionally, MA plan’s networks must include at least one telehealth provider within the Outpatient Behavioral Health specialty.

What Can Veda Do?

Veda’s nationwide database can identify telehealth providers, flag whether a provider accepts patients at their practice location, and help source providers to meet the new behavioral health requirements. We can also help MA plans ensure compliance with CMS’s time and distance standards.

Veda is Equipped to Meet The Needs Introduced By The 2025 CMS Rule Changes

Veda excels at helping health plans and systems connect members with behavioral health services, treatment facilities, and telehealth providers. The 2025 MA rule changes are an opportunity for health plans and health systems to explore how Veda can help them expand, improve, and map their behavioral health networks and verify the claims data for behavioral health providers.

Veda’s solutions can help connect members to quality behavioral health services more quickly, efficiently, and at less cost than the traditional methods relied on in the past. Armed with the most accurate provider data available, Veda’s solutions contribute to positive member experiences while helping people find the right care for their behavioral health needs.

Partner with Veda to Prepare your Behavioral Health Network

 

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CMS Directory Accuracy Audits and Sanctions: Achieving True Directory Accuracy

The Centers for Medicare & Medicaid Services (CMS) regularly audits health plan programs and provider directories. All health plans providing services to Medicare and Medicare Advantage members are nearly guaranteed to be audited by CMS. By definition, the CMS directory accuracy audits aim to improve patient access and experience. Additionally, many standards for provider directories and network adequacy are developed based on CMS regulations.

Veda works with health plans to prepare for CMS audits and then interpret and address their audit results.

Unfortunately, health plans’ directory accuracy claims may not match with CMS’s findings—in the case of lower accuracy discovered, the plans may receive CMS sanctions and fines. Why are the directory accuracy rates differing and what can be done to reconcile the accuracy rates?

Why do accuracy rates determined by CMS and health insurance providers differ?

ai regulation questions

Many factors determine accuracy rates in provider directories. CMS zeroes in on specific fields (such as name, address, and phone number) for determining accuracy while insurance providers may go further in determining accuracy (such as specialty fields). Here are the reasons why updating directories while maintaining high accuracy levels—is an uphill battle:

  • In anecdotes shared by those in the industry, 20–30% of providers are unresponsive during attestation requests. Attestation is not a sufficient data-collection tool and does not result in data quality.
  • Many systems rely on heavily manual workflows, causing delays in data updates. Human error degrades data quality
  • Provider abrasion and long turnaround times are present when constantly attesting to information
  • Phone calls, even when used for verification, have a 20% variability rate. Meaning, if your call center has two people call the same provider twice in one day, you’ll get a different answer 20% of the time

Why Does CMS Audit Provider Directories?

A few years ago, a CMS Online Provider Directory Review Report looked at Medicare Advantage directories and found that 52% had at least one inaccuracy. The areas of deficiency included such errors as:

  • The provider was not at the location listed,
  • The phone number was incorrect, or
  • The provider was not accepting new patients when the directory indicated they were.

And, despite provisions in the 2021 No Surprises Act legislation, new research has shown that directories remain inconsistent, one study citing “of the almost 450,000 doctors found in more than one directory, just 19% had consistent address and specialty information.” (Let alone complete accurate information including phone numbers.) The audits continually find inaccuracies as the years go on.

How Do Health Plans Prepare for CMS Audits?

Traditional approaches to audit preparation include phone calls and mock audits.

Phone Calls

Pricey and oftentimes inconsistent, call campaigns amount to hundreds of thousands of phone calls being made every day to check data.

Mock Audits

Mimics the audit experience with sample sets of small amounts of data but are not reflective of the overall directory.

These approaches are not sufficient for achieving successful audit results.

What Is CMS Looking for in Audits of Directories?

Not all information is equally important during an audit. The scoring algorithm assigns different weights for fields so if you’re starting somewhere, Veda recommends starting with the key areas of focus: Name, Address, Phone, Speciality, and Accepting Patients.

Addressing the most important data elements with quality validated data will move a health plan towards audit success.

How Veda’s Solutions Interpret and Address CMS Audit Results

CMS performs audits to advocate for members and better outcomes so interpreting audit results is the perfect place to get started with directory updates. Our research shows that when it comes to what members care about it is pretty simple: Choice, Accuracy, and Accessibility —meaning the ability to schedule, with their preferred provider, easily and quickly. On the first try. 

Where to Start For CMS Audit Success

Many health plans are realizing that achieving directory accuracy and audit success is not a one-and-done. An ongoing surveillance approach is needed to confidently prepare and ultimately, achieve success in an audit.  

Veda’s approach consistently evaluates the directory to provide ongoing insights. For example, we leverage technology to identify and prioritize providers for updates who haven’t attested recently, to ensure they have a data trail that supports their current status and information in a directory. By prioritizing bad data, this audit strategy is efficient and effective.

Diagnose your provider directory and fix critical data errors ahead of CMS audits with Veda.

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Veda’s provider data solutions help healthcare organizations reduce manual work, meet compliance requirements, and improve member experience through accurate provider directories. Select your path to accurate data.

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The most up-to-date, comprehensive, and accurate data source of healthcare providers, groups, and facilities on the market.

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DIRECTORY ANALYSIS

Review and refresh your network directory to identify areas that affect your quality metrics.

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Resources & Insights

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Meghan Gaffney, CEO and Co-Founder of Veda: The Power Of AI-Driven Data Automation
February 20, 2025
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Q&A with Veda’s Co-Founders: Patented AI Approach for Provider Data
February 6, 2025
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